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P524 Long-term outcomes after restorative proctocolectomy and ileal pouch-anal anastomosis in children compared to adults

Diederen K.*1, Sahami S.2, Tabbers M.1, Benninga M.1, Kindermann A.1, Tanis P.2, Oomen M.3, Bemelman W.2, de Jong J.3

1Dept. of Pediatric Gastroenterology and Nutrition, Academic Medical Center, Amsterdam, Netherlands 2Dept. of Surgery, Academic Medical Center, Amsterdam, Netherlands 3Dept. of Pediatric Surgery, Academic Medical Center, Amsterdam, Netherlands

Background

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the surgical treatment of choice for therapy refractory ulcerative colitis and familial adenomatous polyposis (FAP). There are only a few studies adressing the outcome of IPAA in children compared to adults. This complicates decision making in children with therapeutic refractory UC or FAP. Therefore, we aimed to compare adverse events and pouch function between pediatric and adult patients who underwent IPAA.

Methods

In this cohort study, all consecutive children (<18 years) and adults with a diagnosis of inflammatory bowel disease or FAP that underwent IPAA were included (2000–2015). The IPAA's were performed in a Dutch tertiary referral center by the same team of colorectal surgeons in all subjects in this time period (IPAA's 30–35/year). Demographic and surgical characteristics, and adverse events were obtained by chart review. Pouch function was assessed by phone interview using the Pouch Function Score (PFS, scale 0–30). Differences in adverse events between pediatric and adult patients were analyzed using multivariate regression analysis, corrected for the moment of enrollment during the study period.

Results

In total, 445 patients underwent IPAA: 41 pediatric (median age 15 years) and 404 adult patients (median age 39 years). Median follow-up was 24 months (IQR 8–68). In pediatric patients, overweight, previous abdominal surgeries, open procedures (i.e. colectomy) and defunctioning ileostomy were less prevalent compared to adult patients (p<0.05). All other characteristics, including type of diagnosis and duration of follow-up, were similar (p>0.05).

The occurrence of anastomotic leakage, surgical related fistulas, chronic pouchitis and Crohn's of the pouch (in IBD patients) was not associated with pediatric age, neither was pouch failure on the long-term (table). Pediatric age at IPAA was an independent risk factor for developing anastomotic strictures (OR: 4.2 [95% CI: 1.1–15.8]; p=0.032). These strictures were succesfully treated through a single dilatation in all pediatric and 73% of adult patients. Current pouch function was similar between pediatric and adult patients (median PFS 5.0 vs. 6.0, p=0.164).

Table 1

Pediatric (n=46)Adult (n=426)OR (95% CI)
Anastomotic leakage14%16%0.88 (0.35–2.22)
Pouch stricture10%3%4.22 (1.13–15.77)*
Fistulas related to the pouch2%6%0.63 (0.08–5.21)
Fistulas related to the pouch5%8%0.58 (0.13–2.56)
Crohn's of the pouch^15%6%3.07 (0.87–10.82)
Pouch failure10%6%3.01 (0.89–10.14)

*Significantly associated with adverse outcome in multivariable regression analysis. ^In IBD patients only (n=339.)

Conclusion

Long-term pouch failure rates and pouch function were similar between pediatric and adult patients. There is no need for a more cautious attitude in the application of IPAA in pediatric patients based on concerns of poor outcome on the long term.

References:

[1] K. Diederen, (2016), Table 1